I'm a Canadian who, for a time, worked in the US and had a US health insurance plan (early 2000's), before the ACA. I paid for that health care plan because it had a drug plan and the Ontario health coverage does not. A few times it was convenient to go see a doctor in the US because it was close to the office, and I clearly remember wondering what all those people were doing behind the desk of the doctor's office. In Canada you might see 1 or 2 people in the administrative side of the office, but in a US doctor's office, there seemed to be an army of clerks. I looked into it and it seems like it was all to do with handling all the paperwork due to everyone having a different insurance company. In Ontario there's only one health insurance... the government one, and they just pay for exactly what the doctor bills, there's no "is this covered, is this not", etc. The administrative overhead is much, much lower. The ACA can't possibly have fixed this problem, so you're still paying a lot more overhead for your health care in the US than we are in Canada. Remember, the only "service" an insurance company provides is dividing the costs of a group of people evenly over that entire group. A publicly run insurance scheme doesn't need to pay for advertising, salespeople, lawyers or lawsuits. It's very inexpensive to run, and a lot less hassle for the people who use it.
